Description

Pain in the right upper quadrant (RUQ) can be caused by a wide variety of conditions. The age, sex and general condition of the patient will influence the likely diagnosis. History and examination will also focus the differential diagnosis. Features such as acute or chronic onset, weight loss, pyrexia, general malaise, and urinary or bowel symptoms may all help point to a diagnosis. It is important to decide if there is an acute abdomen.

Presentation

Symptoms

Enquire first about the pain:

• Ask the patient to point to where it is. Does the patient use a single finger or is it more diffuse?
• When did it start?
• Was the onset sudden or gradual?
• Is it continuous or intermittent?
• Describe the nature of the pain - stabbing, burning, gripping, etc. Note the body language and use of hands.
• Are there aggravating or relieving factors?
• Is there any radiation?

Note past medical history. Make a systematic enquiry. The patient may volunteer information such as pyrexia, cough or dysuria.

• Appetite
• Any change in weight
• Bowels
• Urine
• Smoking and drinking
• Medication

Family history may be revealing.

Signs

• Note the general condition of the patient. Is the patient fairly well, shocked, pyrexial or dyspnoeic? Is there jaundice?
• Note temperature, pulse rate and quality, and blood pressure.
• The patient should be adequately disrobed and both the patient and the examiner should be in a comfortable position. A systematic examination of all the abdomen is required. Abdominal examination is described elsewhere. See separate article Abdominal Examination.
• If the diagnosis is still elusive, examination of the respiratory system is indicated.

Differential diagnosis

The crude differential diagnosis is vast but after adequate history and examination it should be very much smaller. The following order is not intended to indicate likelihood:

Liver and gallbladder disease

• Liver disease is usually only painful if it stretches the capsule of the liver, as in congestive heart failure. The liver can be damaged by blunt trauma. Hepato-splenomegaly can occur with malignancy such as lymphoma or chronic myeloid leukaemia or with autoimmune disease including primary biliary cirrhosis.
• The Budd-Chiari syndrome can present with RUQ pain.^[1]
• Gallstones are common and become more common as years advance. Most are asymptomatic but they can cause pain at any time.
• Other gallbladder disease includes carcinoma of the gallbladder, which is always associated with stones too.
• Ascending cholangitis has a classic triad of pain, fever and jaundice.

Bowel lesions

• Lesions of the hepatic flexure include carcinoma, diverticulosis, ischaemic colitis, constipation and Crohn's disease.
• Atypical acute appendicitis must be considered.
• Recurrent symptoms can be caused by irritable bowel syndrome.
• Meckel's diverticulum can present in a variety of ways, usually in children. The diagnosis is usually made at laparotomy. There is often blood loss per rectum.

Cardiovascular disease

• Pain from a dissecting abdominal aortic aneurysm is usually most marked in the back and may originate in the chest and spread down the legs. Other arteries can have aneurysms and bleed.
• Cardiac pain may occasionally present as upper abdominal pain.
• Congestive cardiac failure may stretch the liver capsule.

Renal disorders

• Pyelonephritis.
• Nephrolithiasis.
• Hydronephrosis.
• Renal carcinoma.
• Other disease of the kidney or ureter, including obstruction of the urinary tract.

Respiratory disease

Pain may arise from the right lower lobe of the lungs.

• Lobar pneumonia
• Infarction from pulmonary embolism. If this is suspected, check for evidence of deep vein thrombosis.

Endocrine or exocrine disease

• Diabetic ketoacidosis.
• Addisonian crisis.
• Adrenal tuberculosis.
• Metastatic carcinoma.
• Pain from the pancreas tends to be central and higher in the back, often between the scapulae, although it can be atypical and misleading. Amylase is raised in intestinal obstruction but in acute pancreatitis it is very high.
• Carcinoma of pancreas tends to produce an aching pain between the scapulae, eased on leaning forward.

Infections

• Herpes zoster can present as pain before the typical vesicles appear on the skin. It is the skin that is tender rather than deeper.
• Subphrenic abscess or even gas after laparotomy or, more often, laparoscopy. Pain may also be referred to the shoulder.
• A rare condition is Fitz-Hugh and Curtis syndrome.^[2] There is inflammation of the liver capsule associated with genital tract infection. It is said to occur in up to one fourth of patients with pelvic inflammatory disease. Classically it presents as sharp, pleuritic RUQ pain but signs of salpingitis can be absent.

Pregnancy

The last trimester of pregnancy gives added problems.^[3] Minor elevations of liver enzymes may precede life-threatening disease, such as acute fatty liver of pregnancy (AFLP) or a syndrome of late pregnancy with H aemolysis, E levated L iver enzyme levels, L ow P latelet count (HELLP).

Pre-eclampsia, HELLP syndrome, and AFLP form a spectrum of disease that ranges from mild symptoms to severe life-threatening multiorgan dysfunction. They have been shown to be the primary causes of severe hepatic dysfunction during pregnancy.

Other considerations

• Pain may be referred from nerves in the spinal column or peripheral nerves that supply the area.
• Recurrent abdominal pain is not uncommon in endurance athletes and its diagnosis can be difficult.^[4]
• Children are very non-specific about "tummy pain" and almost anything can present as such. Check ears, throat and urine. Mesenteric adenitis commonly presents with mild pyrexia and probably other lymphadenopathy.
• Lesions associated with left upper quadrant pain may occasionally present on the other side. Situs inversus occurs in 1 person in 10,000.

This list is by no means exhaustive. There are many other rarer causes of abdominal pain, including familial Mediterranean fever, tabes dorsalis and worm infestation. There is also the possibility of Münchhausen's syndrome.

Investigations

The choice of investigations will depend upon the findings above.

• FBC, ESR may give an indication of infection or an inflammatory process. Bleeding may cause anaemia. This may indicate malignancy.
• Abnormal LFTs will occur if the liver is involved and in primary biliary cirrhosis there will be positive autoantibodies for mitochondria. It usually presents in a middle-aged woman with jaundice and pruritis.
• Urinalysis may suggest urinary tract infection, including pyelonephritis or a lesion that causes slight bleeding, such as stones or malignancy.
• Chest X-ray and lateral view may show a lesion of the right lower lobe. Collapse from infection and infarction look similar. Plain abdominal X-rays, erect and supine, may show abnormal bowel patterns, fluid levels or gas or fluid under the diaphragm. 70% of renal stones and 30% of gallstones are radio-opaque.
• Colonoscopy or double contrast barium enema may be required for colonic lesions.
• Ultrasound is useful to investigate the renal tract for stones or dilatation. It is the best way to detect gallstones^[5] and can also check the liver for enlargement and establish if it has an homogeneous pattern or areas of different echo density.
• To investigate the spinal column, CT scan is good at revealing lesions of bone; however, MRI scan is better at showing lesions of the nervous system.
• Abdominal CT or MRI scan may be useful to define a lesion. In overweight people, in whom ultrasound can be difficult, MRI scanning gives similar results.^[6] Radio-isotope imaging can show the liver and spleen.
• In pregnancy, MRI imay be the preferred option. However, CT scanning is increasingly being used in specific cases, eg it is the most reliable method of diagnosing patients with suspected obstruction of the urinary tract due to calculus. Studies suggest that the risk to the fetus from the ionising radiation involved in CT scanning is minimal. If a risk-benefit analysis confirms that CT would be in the patient's best interests, it should not be withheld.